Project Summary/Abstract Sepsis is a life-threatening condition that has doubled in incidence over the past decade, and now constitutes 17% of all in-hospital deaths in the US at an annual cost of $24 billion. Early, aggressive emergency care saves lives, yet many rural hospitals have low adherence to evidence-based sepsis care guidelines. Consequently rural sepsis patients have a 38% higher mortality rate. Rural emergency department (ED)-based telemedicine has been proposed to standardize care and support local clinicians in rural hospitals, but its effectiveness has never been rigorously tested. With 19% of the US population living in rural areas and an estimated 5,000 preventable rural sepsis deaths annually in the US, there is a critical need to test strategies to improve dissemination and implementation of evidence-based sepsis guidelines in rural centers. The goal of this Career Development Award is to prepare the applicant for a career as a clinical investigator and health services researcher focusing on comparative effectiveness research of rural acute care interventions. This goal will be accomplished within the infrastructure of the Rural Telehealth Research Center through (a) specific graduate coursework, (b) a Mentorship Advisory Committee, (c) carefully selected conferences and workshops, and (d) a mentored research study. The specific aims of the proposed study are (1) to measure the association between ED-based telemedicine use, guideline adherence, and clinical outcomes, (2) to measure the effect of a telemedicine relationship on guideline adherence among patients who have telemedicine available but not used, and (3) to describe how and why telemedicine use affects clinical care, decision- making, and dissemination of best practices, using qualitative methods. The proposed mentored research project will accomplish these aims through an observational cohort study of patients with severe sepsis or septic shock treated in critical access hospitals in a large Midwestern telemedicine network over a 4-year period. Our central hypothesis is that telemedicine will improve clinical outcomes through improved adherence with international sepsis guidelines by changing (1) patient-level recommendations, (2) provider-level behavior, and (3) hospital-level practices. At the end of this Career Development Award, the candidate will be well- prepared to become an independent scientist with expertise in rural acute sepsis care, with specific strength in comparative effectiveness research methods and qualitative methods. Our study findings will serve as the basis for future studies to understand the role of dissemination strategies (including telemedicine) on implementing best practices in rural health care settings, which will form the foundation of the candidate's first R01 submission.